Socioeconomic, demographic and environmental factors inform intervention prioritization in urban Nigeria

Nigeria is one of three countries projected to have the largest absolute increase in the size of its urban population and this could intensify malaria transmission in cities. Accelerated urban population growth is out-pacing the availability of affordable housing and basic services and resulting in living conditions that foster vector breeding and heterogeneous malaria transmission. Understanding community determinants of malaria transmission in urban areas informs the targeting of interventions to populations at greatest risk. In this study, we analyzed cluster-level data from the Demographic and Health Surveys (DHS) and the Malaria Indicator Survey (MIS) as well as geospatial covariates to describe malaria burden and its determinants in areas administratively defined as urban in Nigeria. Overall, we found low malaria test positivity across urban areas. We observed declines in test positivity rate over time and identified the percentage of individuals with post-primary education, the percentage of individuals in the rich wealth quintiles, the percentage of individuals living in improved housing in 2015, all age population density, median age, the percentage of children under the age of five that sought medical treatment for fever, total precipitation and enhanced vegetation index as key community predictors of malaria transmission intensity. The unrepresentativeness of the DHS and MIS in urban settings at the state and geopolitical zonal level, regional differences in malaria seasonality across Nigeria, and information detection bias were among likely factors that limited our ability to compare malaria burden across geographic space and ultimately drove model uncertainty. Nevertheless, study findings provide a starting point for informing decisions on intervention prioritization within urban spaces and underscore the need for improved regionally-focused surveillance systems in Nigeria.